by Heidi Van Rooyen, PhD Visiting Scholar, Human Sciences Research Council. Durban, South Africa December 2, 2010

1. Heidi van Rooyen, PhD
1.1. Human Sciences Research Council, South Africa.Human Sciences Research Council, South Africa.
2.2. Visiting Scholar: UCLA, Program in Global Health,Visiting Scholar: UCLA, Program in Global Health,
Los Angeles, USA.Los Angeles, USA.
Zooming in and out: Explorations of HIV
risk, responsibility, intimacy and love

4. • Most infected
heterosexual intercourse
(incl. paid sex)
• Unprotected sex with
multiple partners key risk
factor
• Large proportions PLHA
long term relationships
• Epidemic evolves –
discordant couples
increase, infection in long
term partnership
• New infections – 51%
women
Sub-Sahara Africa

5. 5.7 million people living with HIV (10.6% of population infected)
Adult HIV prevalence rate 16.9 amongst 15-49 year olds
Drivers: migration, low perceptions of risk, and multiple concurrent sexual
partnerships.

9. Context frames question
• Some work in the US and in the UK, but
less so in SA:
–Impact of spiraling HIV infection on risk
management
–Implications for relationship survival as
most not married and do not cohabit

10. AIM:
Explore the strategies heterosexual women in a
rural South African community use in
negotiating issues of HIV risk and responsibility,
intimacy and love in their relationships

11. HIV prevention
• Risk management framed:
– Individual responsible for modifying sexual behaviors
and relationships
– Product of rational decision making
– Provide technologies and skills as solution to the
problem
• Rhodes and Cusick (2002): unprotected sex is not “morally
neutral”
– Carry interpretations of “risk acceptability” and “moral
responsibility”
• Example: Knowingly placing self, others at risk –
irrational/irresponsible
• Less focus on emotions in sexual and relationship risk
management

12. Methodology
• Project Accept (HPTN 043): Multi-site, multifaceted, community
based trial - voluntary counseling and testing (VCT) model in 48
communities in 4 countries (South Africa, Zimbabwe, Tanzania,
and Thailand
• In-depth qualitative interviews conducted at three points during
the study (baseline, 6 months, 15 months).
• Interviews: HIV-related attitudes, norms, and behaviors of the
individual as well as their perceptions of partners’, family
members’, friends’ and community members’ attitudes and
behavior
• Analysis: Topical codes highlighted discussions women had with
partner, attitudes to HIV testing, personal perceptions of risk and
risk reduction strategies

13. Sample
Characteristics of
women
Baseline 6 months 15 months
Age
Younger (18-24) 32 25 18
Older (25-32) 32 22 20
Relationship Status
Single 32 21 16
Coupled 32 26 22
64 47 38

14. Results

15. • Trust and faithfulness critically important issue as sought to
maintain healthy relationships
– Boys will be boys
– Realistic expectations – resignation
– Often acceptance of men having multiple partners
– Took charge – initiating discussions of risk management
both inside, and outside the relationship
• Meanings shifted depending on relationship:
– Permanent lived together
– Casual/Permanent but live apart
– External third parties

16. “He was made like that”
Ha, I would really like to protect myself. I trust
myself as I am just saying. I’m afraid. Okay, I
would never know him. I’m not saying that
maybe there’s something, but he’s a male
person he was made like that. He has got an
eye. The temptation is in the eye. But, I would
be very happy, and I would even sit down with
him and say may we please use this, there’s
not problem sir.
(28 year old woman, couple)(28 year old woman, couple)

17. “You could never know these males”
Uhm because it’s really there (HIV). You can never
run away from it. I can say I am clean. I work, I come
back to my husband… I don’t know what my husband
is doing, you see? And the husband won’t reveal a lot
of things to me. Because even the jacket, …most of
the time they ignore these jackets. He will then be
accepted by a girl in that way, do what he does you
see, then I get it while I am here at home. I can’t say
I’m safe. Yes I can’t know… But according to me, my
behavior… is right…You would just never know these
males.
(31 year old coupled woman)

18. When it comes to AIDS, I can give him
60%
But since you cannot predict a person, but he is a person
who is careful, because when he does something
whatever the circumstances are maybe, if you are in
love, he just means it. Even if something is going to
happen he explains that thing. And that he is not a
person who fails quite often. You see if he does
something, he does it and means it, such that you can
end up guaranteeing him. And that when he says he
loves me, he loves me. So he is by nature like that. His
nature is like that. So when it comes to HIV and AIDS I
think I can give him sixty percent, yes we can give him
[that].” (24 year old, single, female)

19. Weighing up risk
• Context of high risk
– Little evidence of denial
– Rose-tinted glasses off - realistic appraisal
and acknowledgement of risk
• Risk and faithfulness – precarious and
shifting concepts in context of AIDS
– Trust as far as I can see
– Faithfulness, monogamy hard to maintain

20. Faithfulness
• Acknowledgement of risk in discussions of
faithfulness:
“It is just that one should be faithful to the other and not
lose one’s faithfulness because he is now on the other side
because one now sees others. He then comes back to
me…Ey, sometimes I have doubts because I do not know
what he does over there. We can discuss well here and
then behave his own way once he is over there.” (25 year old,
single)
• Faithfulness not always deliberately discussed
• Implied in way risk in own and other relationships
are managed

21. Safety of primary relationship
• Cusick and Rhodes (2000): “rationality of safer sex”
could be in conflict with individual’s and couple’s
efforts to “signal the importance of the relationship”
• Context of viral dangers, rejection of sexual safety
suggests other factors at play
• Our study, we sense this struggle:
– Married women, in long term relationship, or had a
child, less likely to use condoms
– Men offer and women accept idea of no condoms
with the “mother of my child”

22. Mother of his child
“Because I am well behaved. I do not know him
because he does not stay close to where I
stay. No, we do not use it. It is just that from
the beginning we never used it because he
was telling himself that I am the mother of his
child. It is not easy for me to use the condom
as the mother of a child, and I was also telling
myself that he is well-behaved. It would not
be that he goes where I do not know”
(30 year old woman, coupled).

23. Worth the risk
• Rhodes and Cusick (2002): unprotected sex as a
display of faith and trust in the relationship
– Both women (and men) construct the primary
relationship as higher in status and significance
– Unprotected sex is a risk worth taking and safe
enough
– Less a case of denial of viral dangers than
acceptance of danger as part of love and life
• Maximizing intimacy and minimizing risk
different in casual relationships or non-
permanent relationships

24. Risks if live apart
Yes it is just that a person should be well-
behaved because already this thing is there,
you see. That is just what we talk about, which
is that …a person should know himself. Ey if
we have happened to visit each other. We use
the condom. Oh with him. No, we do not
make a mistake. If I have visited him I bring it
for him. Ever since I fell in love with him, we
use it.
(29 year old woman, coupled)

25. Risk from casual relationships
But when we talk I say it must not be like this even outside.
You must really try. Because I see he’s ashamed when I’ve
accidentally seen them (the condoms). He uses them. But
when I accidentally find them in his pockets. It offends him
but I become relieved, happy because it means that he
protects himself. Even if it is said that there’s something that
he’s doing (its OK). Because it means that he’s protected, he
won’t come to me wi… with a big problem, you see. Because
it means he protects himself, because it means that he’s
scared of giving me HIV (28 year old woman, coupled)

26. HIV risk and relationship risk
• Sexual safety constructed differently in non-permanent
relationships:
– Unprotected sex acceptable for more more intimate, permanent
relationships
– Permanent relationships framed in reproductive terms – signs of good
mother and bad women
– Mindry et al., 2010: concerns about children or desires to have
children are effectively used by men and women to raise concerns
about HIV risk in their relationships
• van Campenhoudt, 1999: “Not using one, connotes trust.
Using a condom can be interpreted as marking the desire to
maintain a distance”
– Physical and emotional distance
– “Casual” relationships – meaningless
– Closeness, trust and love of condom-free
relationships

27. Meet Nolwazi…

28. Part 1: “A person knows where they’ve passed”
Why wouldn’t I have it? You see, because a person knows
where they’ve passed— that I passed here, and here and
here, and passed there. Now, uhm, oh… all the chances are
in my favour that I’m positive.
Because the father of my child died… but despite that I
cannot judge him. I don’t know what killed him.
Secondly, my sister got sick. I was not understanding about
this disease at that time. I was caring for her in whatever
way. So there were many chances that, you see, I would get
this disease.
Thirdly, this was not the first or last guy that I dated. I
travelled the world, I did travel. If I got…ah… I would have
gotten what I deserved.

29. Part 2: “We were really in love, you hear me?
This guy I was in love with, in a relationship, we were
in love, and he was my friend. We were really in love,
you hear me?
When I first went to his place, it was during the day,
and when I got there, he said, “Hey, how about sex?”
and I said “Hey, how about a condom?”
And he said, “How about no condom. It gives me
problems with my bladder.”
Then I said, “No, stop it then…”

30. You see—he backed down on that day, and he was
like, “It’s fine.” And then, it continued, we carried on
going out.
And it happened when I went to visit him properly
[going to stay overnight or have sex] and this time, I
said, “How about a condom.”
“No, it gives me problems with the bladder.”
He knew that he’s taking treatment [ARV therapy]
but still he just slept with me without using a
condom.

31. Part 3: An apology doesn’t help
After some time, eh… what can I say? Guys have this thing
that… ‘With this person, I’m just passing by. I’m not staying.’ So if
you’re just passing by—you don’t love her— does that mean you have
to kill her? So when he realized our relationship was becoming serious
and deep, that was when he started to hold his head and say,
‘Bru, there has been a mistake that happened here.’
‘Bru, how did you do it?’
‘Ei, bru, I don’t know.’
You know how guys are; they just sleep with us cherries [slang for
girls]. It’s an apology. You see, an apology, bru, doesn’t help, bru,
because a person has just ended your life.

32. The thing is that, when this happened, I already had that
thing that, maybe I’ve killed somebody’s child. Because
even myself, I wasn’t sure about myself. So in telling me, I
just knew for sure that I’m positive, and like I’m telling you,
he is the person who is always encouraging me to test, and
not to rush, I must just wait, accept, and be grand.
‘And I will always be there to support you in whatever way
that I can support you’ [words spoken by her partner].
That is why… I do … not worry about the virus anymore
because I know that already…It is just something that is
there and it is something which I have. The only thing that
worries me if I die is Awu, what about my child? That is it.

33. Part 4: “Love covers everything. But he killed me.”
The interviewer asks,
How did you feel after he had told you that?
Nolwazi says,
I hated him, I don’t want to lie. I really hated him and it
took a while for everything to be back where it’s
supposed to be, because I’ve asked myself whether, Ok,
fine, am I leaving him? I’m just leaving him…and the one
I will start going out with, would he not be positive? How
could I be sure? Another person could still do the same
thing that he has done. I have that thing that, Oh god, I
was just killed by this one. But I also say sometimes
that… you know, love, it covers everything, no matter
how bad it is. But it covers. But he killed me.

34. Epilogue: “I thank him for his conscience…
that he had a conscience, in the end”
Nolwazi continues:
He often tells me that if you are HIV po- [positive], that does
not mean it’s the end of your life. He’s the one who makes me
understand about this disease
The interviewer asks,
Mmm, okay, eh… how do you feel when he says that?
Nolwazi says,
I feel grateful, I just feel grateful that, eneh, I have a person
like him. Because if it was someone else, maybe he wouldn’t
care. Because so many people are doing it. A person passes…
how can I say this? I thank him for his conscience, that he had
a conscience, in the end. Because if were someone else, he
would have just kept quiet, and said, ‘If she dies, she dies.
Me, also, if I die, I die.’

35. HIV risk, responsibility and love
• Managing HIV risk, looks for ways to forgive her
partner and restore a sense of normalcy
– Creates a narrative that focuses on his honesty, decency,
love, and support for her
• More women like Nolwazi – the impulse to mend
relationships and find forgiveness, to help
relationships survive in context of HIV
• Long (2008): “Who is to blame – not only a question
of “who infected me”
– because of the morality and stigma attached to HIV/AIDS,
always questions of right and wrong, good and bad
– complicated in context of high prevalence

36. Implications for prevention
• Signs of vulnerable women: want to use condoms,
lack agency, afraid, reluctant
• Stronger voices those that challenged notion ALLALL
women are vulnerable and lack agency
• Schatz (2005) rural Malawi: women display
considerable agency in managing risks as try to
preserve relationships
• Work with women need to address their diversity
• Value of women as mothers – here and Mindry et
al–hook to get women and men to talk about risk
• Couples testing and prevention for serodiscordant
couples

37. Conclusions
• Risk management and prevention is complicated
• HIV prevention has discounted the irrationality of
emotion, and love and how these impact risk
management
• Love and intimacy key features of relationship survival,
complicated under the threat of HIV transmission and
illness
• Technical solutions to HIV, do not always acknowledge
the context and meanings associated with risk
management
• Meanings are different depending on the relationship,
need to be addressed from inside out

38. Acknowledgements
• Cusick, L., & Rhodes, L (2000). Sustaining sexual safety in
relationships: HIV positive people and their sexual partners.
Culture, Health and Sexuality 2, 4: 473-87.
• Mindry, D., Maman., S; Chirowodza., A.; Muravha, T; van
Rooyen. H., and Thomas Coates. Looking to the future: South
African men and women negotiating HIV risk and relationship
intimacy (NIMH Project Accept/HPTN 043). Culture Health and
Sexuality
• Rhodes, T. & Cusick, L (2002). Accounting for unprotected sex:
stories of agency and acceptability. Social Science and Medicine,
55, 211-226
• Van Campenhoudt, L. 1999. Commentary: The relational
rationality of risk and uncertainty reducing processes explaining
HIV risk-related sexual behaviour. Culture, Health and Sexuality
1, 2: 181-91.